Audit

THIS CHECKLIST IS TO BE COMPLETED PRIOR TO ALL CONFINED SPACE ENTRIES AND RETAINED FOR AT LEAST ONE MONTH . Checklist must be completed by a CSE Competent Person.

1. IDENTIFICATION
Date and Time of Entry

Entry/Access Permit Number

Confined Space Location

Description of Works

Manhole No

Site Photo
2. PERSONNEL

Enter the names of Entry Personnel and Expiry Date of CSE Ticket

Enter the names of Surface Personnel and Expiry Date of CSE Ticket

Relevant Emergency contact numbers are accessible on site ?

3.ISOLATION

Electrical Isolation Required

Mechanical Isolation Required

Contact with System Operator Required

Required Isolation in Place - Checked by

Signiture
4. ATMOSPHERIC TESTING
Gas Detector Calibration Date

Recommended Levels

Oxygen b/w 19.5% to 23.5% : Explosive Gas <5% LEL : Hydrogen Sulphide <10ppm : Carbon Monoxide <30ppm

Record Peak Test Readings Prior To Entry

Oxygen (%)

Explosive Gas (LEL%)

Hydrogen Sulphide (ppm)

Carbon Monoxide (ppm)

Other Gases Tested

Record any

5. VENTILATION

Natural

Forced

Wash Down

6. REVIEW CONDITIONS THAT MAY CHANGE STATUS OF CSE

Select any of the following that will be taken into consideration before entry into the Confined Space

Weather

Traffic

Noise

Catchment

Flow Volume

Trade Waste Discharge

Industrial/Commercial Discharge

Domestic Discharge

7. PERSONAL PROTECTION EQUIPMENT

Select relevant PPE to be worn or carried by persons entering the Confined Space.

First Aid Kit

Helmet, Boots, Safety Vest

Gloves

Eye Protection

Hearing Protection

Overalls, Chemical Suite

Waders

2 Way Radio

Gas Detector

Self Rescue Respirator

Fall Arrest Device

Lifeline

Harness

Airline

Road Signage

Platforms

Barricades

Lighting

Bosun

Ladders

Man Cage

Fire Extinguisher

8. HOT WORK

Has the area been cleared of combustible materials for 15m ?

Have all drains within 15m been covered with a wet fireproof blanket ?

Will hot work be performed in the Confined Space ?

Are appropriate fire extinguishes on site ?
List the type of Extinguishers .

Is a water hose available & tested on site ?
If no, list precautions taken to substitute a water hose.

Is extra ventilation required ?
If "YES" what type and where will it be located.

All power leads clear of pipelines ?

All power leads clear of access way ?

Will the Hot works release toxic vapours ?
If "YES", describe the controls to be implemented to enable Hot Works to be performed safely.

8.1. Welders

Are welding machines/gas bottles at least 8m from the manhole/pit entry ?

Are electric welders earthed ?

Are welders serviced to manufacturers specifications ?

Welders Name & Signature
8.2. Authority to perform "HOT WORKS" works

I have checked the above conditions and consider it safe to carry out this work.

Name & Signiture
Select date
9. CITY WEST WATER ENTRY

CONTACT CITY WEST WATER FOR ENTRY TIME - 9313 8499

Time phoned IN (Entry)
Time of intended EXIT

CWW Operator Name

10. APPROVAL TO ENTER

The Confined Space described in this Entry Checklist is in my opinion safe to enter using precautions listed above and all persons are properly trained to perform this work.

Name and Signature
Select date
11. JOB COMPLETION

All persons have left the Confined Space. No further Entries Permitted without New Permit

Name and Signature
Select date
12. CITY WEST WATER EXIT

CONTACT CITY WEST WATER FOR EXIT TIME - 9313 8499

Time of EXIT

CWW Operator Name